Affording Care: A Medical Student's Story

Published: Aug 24, 2013 | Updated: Aug 25, 2013 By Ben Hartman, MD, Contributing Writer, MedPage Today The Affordable Care Act as approved by Congress required all insurance plans to limit personal out-of-pocket expenses to $6,350 for individual plans and $12,700 for family plans. That requirement was set to kick in next year, but the Obama administration has since extended the time to implement that out-of-pocket cap until 2015. This delay will cover all "grandfathered" group plans: health plans for employees, students, professional groups, trade associations, and labor unions. Three possible scenarios, from financial pain to financial ruin, may ensue as a result of this policy delay. If a plan, which already has out-of-pocket maximums (OPMs) in place, uses a third party administrator (e.g., Express Scripts, Medco) for certain benefits, the insured may be responsible for an additional $6,350/$12,700 for those benefits (usually prescription drug and mental health coverage). This could lead to a doubling of annual out-of-pocket payments: $12,700 for individuals and $25,400 for families. If a "grandfathered" plan uses third parties for both its mental health and prescription drug benefits, this could lead to a tripling of out-of-pocket costs for the policy holder. If the third party administrator forgoes OPMs, the policyholder could pay unlimited copays for their medications and mental health services. Even worse, if the primary insurer (e.g., Aetna, United Healthcare) places an annual limit on its total benefit payouts, then the insured could be responsible for 100% of their medical costs after the provider reaches its annual limit. Confused? I'll try to clear it up with a personal story. In June 2012, I was diagnosed with cancer. My medical school's health plan, Aetna, provided my health coverage. I decided to seek treatment at the Mayo Clinic, which was in Aetna's network. Under my plan, Aetna would pay up to $2 million per condition per policy year for medical services. They would pay up to $100,000 annually for prescription drug costs. My OPM for medical services was $7,500; they didn't offer an OPM for prescription drug coverage. Therefore, once I paid my $300 deductible and $7,500 out-of-pocket expenses, which happened within 3 weeks of my diagnosis, Aetna (kindly) picked up the rest of my tab. To date, Aetna has paid more than $500,000 for my medical care. Unlike many cancer patients, I don't need follow up cancer medications, which are often extraordinarily expensive. Because of this, I haven't exceeded my $100,000 maximum for prescription drugs. But even with good insurance, helpful guidance from Mayo and Aetna, and a solid understanding of the health care industry, I will end up paying at least $15,000 in out-of-pocket costs for my cancer care (this is a combination of medical services and prescription drug costs). It could have been much worse. In the 2010-2011 academic year, my school's insurance plan had an annual limit of $100,000. Today, there are still "grandfathered" university health plans with an annual limit of $100,000, according to the American College Health Association, an organization dedicated to improving the healthcare for university students. For the 2014 academic year, "grandfathered" student health plans, which started between July 1, 2012 and Sept. 23, 2012, can continue to set an annual payout limit of $100,000. If the policy began on or after Sept. 23, 2012, it can have a $500,000 annual limit. Payment for prescription drugs and mental health benefits are included in these annual limits. If my university plan had a $100,000 annual limit, I would owe more than $500,000 in out-of-pocket expenses for my cancer treatment. This is why it's essential to have adequate healthcare -- even for medical students. According to Isabel Goldenberg, MD, medical director of George Washington University's Student Health Center, "Two unique things about this population (students and young adults) are that they don't feel they need insurance because they are young, and it's also a population that has a lot of accidents." For those reasons, this demographic needs extra encouragement to take healthcare coverage seriously. With that in mind, I've devised an acronym that I think will be helpful for anyone who will be entering the health insurance market. I call it: PAID COSTS. • Premiums • Annual Limits • Immunity to illness (Remind yourself that you aren't immune) • Deductibles • Coverage (Will the plan cover my current providers and will it provide nationwide coverage in the event that I need to travel for treatment?) • Out-of-pocket costs • Sickness (What current medical problems do I need my insurer to cover?) • Treatments (What medical treatments do I currently need?) • Symptoms (Am I experiencing any symptoms that need to urgent attention will my insurer cover this problem?) Open enrollment for 2014 is, or will soon be, offered for student, employer, and -- come this October -- ACA exchange plans. Most medical schools don't even teach their students about America's current and evolving healthcare system. Aside from nutrition education, this is probably the most important topic that medical educators ignore. But, as I know, ignorance is far from bliss. http://www.medpagetoday.com/Washington-Watch/Reform/41167?xid=nl_mpt_DHE_2013-08-26&utm_content=&utm_medium=email&utm_campaign=DailyHeadlines&utm_source=WC&eun=g350341d0r&userid=350341&email=john@thebrokerageinc.com&mu_id=5344066